White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC

Facility

$45,546.80

Service Code	MSDRG 330
Min. Negotiated Rate	$20,975.50
Max. Negotiated Rate	$45,546.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22,329.23
Rate for Payer: Amerigroup Medicare	$22,329.23
Rate for Payer: BCBS of TX Medicare	$22,329.23
Rate for Payer: Cigna Commercial	$30,875.94
Rate for Payer: Cigna Medicare	$22,329.23
Rate for Payer: Employer Direct Commercial	$22,329.23
Rate for Payer: Humana Medicare/TRICARE	$22,329.23
Rate for Payer: Molina Dual Medicare/Medicaid	$22,329.23
Rate for Payer: Molina Medicare	$22,329.23
Rate for Payer: Multiplan Auto	$45,546.80
Rate for Payer: Multiplan Commercial	$45,546.80
Rate for Payer: Multiplan Workers Comp	$45,546.80
Rate for Payer: Scott and White EPO/PPO	$20,975.50
Rate for Payer: Scott and White Medicare	$22,329.23
Rate for Payer: Superior Health Plan EPO	$22,329.23
Rate for Payer: Superior Health Plan Medicare	$22,329.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$22,329.23
Rate for Payer: Universal American Medicare	$22,329.23
Rate for Payer: Wellcare Medicare	$22,329.23
Rate for Payer: Wellmed Medicare	$22,329.23

MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC

Facility

$87,333.50

Service Code	MSDRG 329
Min. Negotiated Rate	$38,447.94
Max. Negotiated Rate	$87,333.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$38,447.94
Rate for Payer: Amerigroup Medicare	$38,447.94
Rate for Payer: BCBS of TX Medicare	$38,447.94
Rate for Payer: Cigna Commercial	$59,202.92
Rate for Payer: Cigna Medicare	$38,447.94
Rate for Payer: Employer Direct Commercial	$38,447.94
Rate for Payer: Humana Medicare/TRICARE	$38,447.94
Rate for Payer: Molina Dual Medicare/Medicaid	$38,447.94
Rate for Payer: Molina Medicare	$38,447.94
Rate for Payer: Multiplan Auto	$87,333.50
Rate for Payer: Multiplan Commercial	$87,333.50
Rate for Payer: Multiplan Workers Comp	$87,333.50
Rate for Payer: Scott and White EPO/PPO	$40,219.38
Rate for Payer: Scott and White Medicare	$38,447.94
Rate for Payer: Superior Health Plan EPO	$38,447.94
Rate for Payer: Superior Health Plan Medicare	$38,447.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$38,447.94
Rate for Payer: Universal American Medicare	$38,447.94
Rate for Payer: Wellcare Medicare	$38,447.94
Rate for Payer: Wellmed Medicare	$38,447.94

MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC

Facility

$31,975.10

Service Code	MSDRG 331
Min. Negotiated Rate	$14,574.42
Max. Negotiated Rate	$31,975.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,094.09
Rate for Payer: Amerigroup Medicare	$17,094.09
Rate for Payer: BCBS of TX Medicare	$17,094.09
Rate for Payer: Cigna Commercial	$21,675.75
Rate for Payer: Cigna Medicare	$17,094.09
Rate for Payer: Employer Direct Commercial	$17,094.09
Rate for Payer: Humana Medicare/TRICARE	$17,094.09
Rate for Payer: Molina Dual Medicare/Medicaid	$17,094.09
Rate for Payer: Molina Medicare	$17,094.09
Rate for Payer: Multiplan Auto	$31,975.10
Rate for Payer: Multiplan Commercial	$31,975.10
Rate for Payer: Multiplan Workers Comp	$31,975.10
Rate for Payer: Scott and White EPO/PPO	$14,725.38
Rate for Payer: Scott and White Medicare	$17,094.09
Rate for Payer: Superior Health Plan EPO	$17,094.09
Rate for Payer: Superior Health Plan Medicare	$17,094.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,094.09
Rate for Payer: Universal American Medicare	$17,094.09
Rate for Payer: Wellcare Medicare	$17,094.09
Rate for Payer: Wellmed Medicare	$17,094.09

MAJOR SMALL BOWEL PROCEDURES

Facility

$39,875.67

Service Code	APR-DRG 2304
Min. Negotiated Rate	$37,596.18
Max. Negotiated Rate	$39,875.67
Rate for Payer: Amerigroup CHIP/Medicaid	$37,596.18
Rate for Payer: Cigna Medicaid	$37,596.18
Rate for Payer: Molina CHIP/Medicaid	$37,596.18
Rate for Payer: Parkland Medicaid	$37,596.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39,875.67

MAJOR SMALL BOWEL PROCEDURES

Facility

$6,716.98

Service Code	APR-DRG 2301
Min. Negotiated Rate	$6,333.01
Max. Negotiated Rate	$6,716.98
Rate for Payer: Amerigroup CHIP/Medicaid	$6,333.01
Rate for Payer: Cigna Medicaid	$6,333.01
Rate for Payer: Molina CHIP/Medicaid	$6,333.01
Rate for Payer: Parkland Medicaid	$6,333.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,716.98

MAJOR SMALL BOWEL PROCEDURES

Facility

$14,661.34

Service Code	APR-DRG 2303
Min. Negotiated Rate	$13,823.22
Max. Negotiated Rate	$14,661.34
Rate for Payer: Amerigroup CHIP/Medicaid	$13,823.22
Rate for Payer: Cigna Medicaid	$13,823.22
Rate for Payer: Molina CHIP/Medicaid	$13,823.22
Rate for Payer: Parkland Medicaid	$13,823.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,661.34

MAJOR SMALL BOWEL PROCEDURES

Facility

$9,846.52

Service Code	APR-DRG 2302
Min. Negotiated Rate	$9,283.64
Max. Negotiated Rate	$9,846.52
Rate for Payer: Amerigroup CHIP/Medicaid	$9,283.64
Rate for Payer: Cigna Medicaid	$9,283.64
Rate for Payer: Molina CHIP/Medicaid	$9,283.64
Rate for Payer: Parkland Medicaid	$9,283.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,846.52

MAJOR SMALL & LARGE BOWEL PROCEDURES W CC

Facility

$45,546.80

Service Code	MSDRG 330
Min. Negotiated Rate	$20,975.50
Max. Negotiated Rate	$45,546.80
Rate for Payer: BCBS of TX Blue Advantage	$21,700.38
Rate for Payer: BCBS of TX Blue Essentials	$26,037.93
Rate for Payer: BCBS of TX PPO	$28,932.16

MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC

Facility

$87,333.50

Service Code	MSDRG 329
Min. Negotiated Rate	$38,447.94
Max. Negotiated Rate	$87,333.50
Rate for Payer: BCBS of TX Blue Advantage	$42,937.22
Rate for Payer: BCBS of TX Blue Essentials	$51,519.67
Rate for Payer: BCBS of TX PPO	$57,246.30

MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC

Facility

$31,975.10

Service Code	MSDRG 331
Min. Negotiated Rate	$14,574.42
Max. Negotiated Rate	$31,975.10
Rate for Payer: BCBS of TX Blue Advantage	$14,574.42
Rate for Payer: BCBS of TX Blue Essentials	$17,487.61
Rate for Payer: BCBS of TX PPO	$19,431.43

MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES

Facility

$8,825.85

Service Code	APR-DRG 2202
Min. Negotiated Rate	$8,321.32
Max. Negotiated Rate	$8,825.85
Rate for Payer: Amerigroup CHIP/Medicaid	$8,321.32
Rate for Payer: Cigna Medicaid	$8,321.32
Rate for Payer: Molina CHIP/Medicaid	$8,321.32
Rate for Payer: Parkland Medicaid	$8,321.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,825.85

MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES

Facility

$17,349.94

Service Code	APR-DRG 2203
Min. Negotiated Rate	$16,358.13
Max. Negotiated Rate	$17,349.94
Rate for Payer: Amerigroup CHIP/Medicaid	$16,358.13
Rate for Payer: Cigna Medicaid	$16,358.13
Rate for Payer: Molina CHIP/Medicaid	$16,358.13
Rate for Payer: Parkland Medicaid	$16,358.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,349.94

MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES

Facility

$47,141.08

Service Code	APR-DRG 2204
Min. Negotiated Rate	$44,446.26
Max. Negotiated Rate	$47,141.08
Rate for Payer: Amerigroup CHIP/Medicaid	$44,446.26
Rate for Payer: Cigna Medicaid	$44,446.26
Rate for Payer: Molina CHIP/Medicaid	$44,446.26
Rate for Payer: Parkland Medicaid	$44,446.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$47,141.08

MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES

Facility

$7,226.56

Service Code	APR-DRG 2201
Min. Negotiated Rate	$6,813.46
Max. Negotiated Rate	$7,226.56
Rate for Payer: Amerigroup CHIP/Medicaid	$6,813.46
Rate for Payer: Cigna Medicaid	$6,813.46
Rate for Payer: Molina CHIP/Medicaid	$6,813.46
Rate for Payer: Parkland Medicaid	$6,813.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,226.56

MAJOR THUMB OR JOINT PROCEDURES

Facility

$22,792.40

Service Code	MSDRG 506
Min. Negotiated Rate	$10,496.50
Max. Negotiated Rate	$22,792.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,648.41
Rate for Payer: Amerigroup Medicare	$14,648.41
Rate for Payer: BCBS of TX Blue Advantage	$12,128.58
Rate for Payer: BCBS of TX Blue Essentials	$14,552.89
Rate for Payer: BCBS of TX Medicare	$14,648.41
Rate for Payer: BCBS of TX PPO	$16,170.50
Rate for Payer: Cigna Commercial	$15,450.85
Rate for Payer: Cigna Medicare	$14,648.41
Rate for Payer: Employer Direct Commercial	$14,648.41
Rate for Payer: Humana Medicare/TRICARE	$14,648.41
Rate for Payer: Molina Dual Medicare/Medicaid	$14,648.41
Rate for Payer: Molina Medicare	$14,648.41
Rate for Payer: Multiplan Auto	$22,792.40
Rate for Payer: Multiplan Commercial	$22,792.40
Rate for Payer: Multiplan Workers Comp	$22,792.40
Rate for Payer: Scott and White EPO/PPO	$10,496.50
Rate for Payer: Scott and White Medicare	$14,648.41
Rate for Payer: Superior Health Plan EPO	$14,648.41
Rate for Payer: Superior Health Plan Medicare	$14,648.41
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,648.41
Rate for Payer: Universal American Medicare	$14,648.41
Rate for Payer: Wellcare Medicare	$14,648.41
Rate for Payer: Wellmed Medicare	$14,648.41

MALE POST 1 HOLE

Facility

$1,168.67

Service Code	HCPCS C1734
Hospital Charge Code	992229
Hospital Revenue Code	278
Min. Negotiated Rate	$105.18
Max. Negotiated Rate	$841.44
Rate for Payer: Amerigroup CHIP/Medicaid	$105.18
Rate for Payer: BCBS of TX Blue Advantage	$350.60
Rate for Payer: BCBS of TX Blue Essentials	$420.72
Rate for Payer: BCBS of TX PPO	$467.47
Rate for Payer: Cash Price	$794.70
Rate for Payer: Cigna Medicaid	$841.44
Rate for Payer: Molina CHIP/Medicaid	$841.44
Rate for Payer: Multiplan Auto	$584.34
Rate for Payer: Multiplan Commercial	$584.34
Rate for Payer: Multiplan Workers Comp	$584.34
Rate for Payer: Parkland Medicaid	$841.44
Rate for Payer: Scott and White EPO/PPO	$584.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$841.44
Rate for Payer: Superior Health Plan EPO	$158.94

MALE POST 1 HOLE

Facility

$1,168.67

Service Code	HCPCS C1734
Hospital Charge Code	992229
Hospital Revenue Code	278
Min. Negotiated Rate	$292.17
Max. Negotiated Rate	$584.34
Rate for Payer: Cash Price	$794.70
Rate for Payer: Cigna Commercial	$292.17
Rate for Payer: Multiplan Auto	$584.34
Rate for Payer: Multiplan Commercial	$584.34
Rate for Payer: Multiplan Workers Comp	$584.34
Rate for Payer: Scott and White EPO/PPO	$584.34

MALE POST 2 HOLE

Facility

$1,168.67

Service Code	HCPCS C1734
Hospital Charge Code	992230
Hospital Revenue Code	278
Min. Negotiated Rate	$105.18
Max. Negotiated Rate	$841.44
Rate for Payer: Amerigroup CHIP/Medicaid	$105.18
Rate for Payer: BCBS of TX Blue Advantage	$350.60
Rate for Payer: BCBS of TX Blue Essentials	$420.72
Rate for Payer: BCBS of TX PPO	$467.47
Rate for Payer: Cash Price	$794.70
Rate for Payer: Cigna Medicaid	$841.44
Rate for Payer: Molina CHIP/Medicaid	$841.44
Rate for Payer: Multiplan Auto	$584.34
Rate for Payer: Multiplan Commercial	$584.34
Rate for Payer: Multiplan Workers Comp	$584.34
Rate for Payer: Parkland Medicaid	$841.44
Rate for Payer: Scott and White EPO/PPO	$584.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$841.44
Rate for Payer: Superior Health Plan EPO	$158.94

MALE POST 2 HOLE

Facility

$1,168.67

Service Code	HCPCS C1734
Hospital Charge Code	992230
Hospital Revenue Code	278
Min. Negotiated Rate	$292.17
Max. Negotiated Rate	$584.34
Rate for Payer: Cash Price	$794.70
Rate for Payer: Cigna Commercial	$292.17
Rate for Payer: Multiplan Auto	$584.34
Rate for Payer: Multiplan Commercial	$584.34
Rate for Payer: Multiplan Workers Comp	$584.34
Rate for Payer: Scott and White EPO/PPO	$584.34

MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY

Facility

$4,657.15

Service Code	APR-DRG 5013
Min. Negotiated Rate	$4,390.93
Max. Negotiated Rate	$4,657.15
Rate for Payer: Amerigroup CHIP/Medicaid	$4,390.93
Rate for Payer: Cigna Medicaid	$4,390.93
Rate for Payer: Molina CHIP/Medicaid	$4,390.93
Rate for Payer: Parkland Medicaid	$4,390.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,657.15

MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY

Facility

$6,179.86

Service Code	APR-DRG 5014
Min. Negotiated Rate	$5,826.59
Max. Negotiated Rate	$6,179.86
Rate for Payer: Amerigroup CHIP/Medicaid	$5,826.59
Rate for Payer: Cigna Medicaid	$5,826.59
Rate for Payer: Molina CHIP/Medicaid	$5,826.59
Rate for Payer: Parkland Medicaid	$5,826.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,179.86

MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY

Facility

$3,139.34

Service Code	APR-DRG 5012
Min. Negotiated Rate	$2,959.88
Max. Negotiated Rate	$3,139.34
Rate for Payer: Amerigroup CHIP/Medicaid	$2,959.88
Rate for Payer: Cigna Medicaid	$2,959.88
Rate for Payer: Molina CHIP/Medicaid	$2,959.88
Rate for Payer: Parkland Medicaid	$2,959.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,139.34

MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY

Facility

$1,883.30

Service Code	APR-DRG 5011
Min. Negotiated Rate	$1,775.65
Max. Negotiated Rate	$1,883.30
Rate for Payer: Amerigroup CHIP/Medicaid	$1,775.65
Rate for Payer: Cigna Medicaid	$1,775.65
Rate for Payer: Molina CHIP/Medicaid	$1,775.65
Rate for Payer: Parkland Medicaid	$1,775.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,883.30

MALFUNCTION, REACTION AND COMPLICATION OF GASTROINTESTINAL DEVICE OR PROCEDURE

Facility

$3,493.52

Service Code	APR-DRG 2522
Min. Negotiated Rate	$3,293.82
Max. Negotiated Rate	$3,493.52
Rate for Payer: Amerigroup CHIP/Medicaid	$3,293.82
Rate for Payer: Cigna Medicaid	$3,293.82
Rate for Payer: Molina CHIP/Medicaid	$3,293.82
Rate for Payer: Parkland Medicaid	$3,293.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,493.52

MALFUNCTION, REACTION AND COMPLICATION OF GASTROINTESTINAL DEVICE OR PROCEDURE

Facility

$5,154.29

Service Code	APR-DRG 2523
Min. Negotiated Rate	$4,859.64
Max. Negotiated Rate	$5,154.29
Rate for Payer: Amerigroup CHIP/Medicaid	$4,859.64
Rate for Payer: Cigna Medicaid	$4,859.64
Rate for Payer: Molina CHIP/Medicaid	$4,859.64
Rate for Payer: Parkland Medicaid	$4,859.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,154.29

Know your out-of-pocket cost for care.

All Charges